Carrie Wisenfeldr
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IV\ I ANA I it Ei-='-,, :,--
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DIVERSITY STATISTICS REPORTING
Name:
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Board / Committee: Pi a titA A ,..,a cAn Ci)c)yr rY) I' a;i f,Y1 fl-0 I WO WI @ V)
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Appointment Date: i 1 i /
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Pursuant to City of-Miami Beach Ordinarke 2009-363'2, th&City is required to annually
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prepare and_present.6- report to the,‘Oity C-6mssibri 'identifying the City's diversity
statistics. This form allows board and committee applicants and members to voluntarily
self-identify their race, ethnicity, disabled status and gender.
Please check the appropriate box for each category:
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Gender: Male Lm—li Female
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RacelEthnic•Categories', . ‘ ' •
. What is your race?
I:3 African-American/Black
, Caucasian/VVhite .
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[:24 Asian or Pacific Islander .
• Native-American/American Indian .
r:a Other— Print Race:
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Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
, JO No • .•
I:3 Yes
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Do,you consider yourself Physically Disabled?
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No , ..,.
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L:3 Yes
Signature: , ,e....x-- -------- -12-edtV Date:
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FACLEIWALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form'05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 '' .
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